Over or under activity in people with chronic pain

There is plenty of research showing that the relationship between pain intensity and limitations in daily life is unclear. There is also ample evidence showing that the relationship between tissue damage and pain is unclear. Add all three components together and it’s easy to see that trying to work out whether a person is unable to do something, or is simply unwilling to do something is complicated. It’s also important.

When we look at activity patterns across a day or week, each one of us has a different “typical” profile. Some of us are morning people (I’m not), with higher levels of activity in the morning, tailing off to less over the day. Some are night owls and peak activity might be at night. Different types of work also shape our activity profile – if you’re a business person you may spend a great deal of the day sitting in a desk, getting physically active only when going out for a fitness activity while there are plenty of tradespeople who work very hard throughout the day, but spend the evening in front of the telly. And of course shiftwork, days off from paid work, and home responsibilities like cooking meals, cleaning the house, caring for children, doing the garden also contribute to the variability in a person’s daily activities.

So it’s difficult to tell what activity profile is “normal”. How on earth do we tell whether someone is able to do more? And how do we define “over activity” or “persistence” and “under activity” or “avoidance”?

Activity management is coming under scrutiny more and more. Pacing, or ““the active self-management strategy whereby individuals learn to balance time spent on activity and rest for the purpose of achieving increased function and participation in meaningful activities” (Jamieson-Lega, Berry, & Brown. 2013, p. 207) is routinely used in pain management programmes to help people gain more capacity to do what is important in their lives. To use pacing effectively people living with pain need to estimate what they’re currently doing – are they pushing, or overdoing, then busting or avoiding?

In the current discussion, Van Damme and Kindermans (in press) present a self-regulation perspective on activity patterns. Within this model, behaviour, or what we do, emerges from a range of motivational factors or goals. We change our behaviour to better achieve valued goals, and adjust according to an internal “standard” we develop. Van Damme and Kindermans argue that, within this model, avoidance and persistence are not so much about how pain is interpreted, but more related to regulating the actions we take in relation to important goals. They review a number of theories relevant to self regulation, including self-identity such that avoidance and persistence can be seen as ways individuals try to restore a sense of “normal” self by reducing the discrepancy between what they think they should be achieving (and how), and what they can achieve. They go on to look at “affective-motivational” theory in which over-activity might be associated with feeling positive, feeling good results in doing “too much”, subsequently leading to stopping when mood drops as pain increases. This model is also associated with the intrinsic value the person places on the activity – if the focus is on “I’m going to do as much as I can”, satisfaction rests on how much progress towards the end point is achieved, while “I’ll do as much until I feel like stopping” means the focus is on enjoyment levels in the tasks.

Van Damme and Kindermans also discuss goal cognition, or that people have a “mind model” of how they typically go about achieving a goal. People living with pain may develop a new model of the effect of pain on the ways they go about achieving goals, and this may influence how a person responds to pain fluctuations. Their final model is coping, in which they describe either an assimilating process, where efforts focus on changing factors getting in the way of the goal or by working harder so it can be achieved, or an accommodating process where goals are reappraised and adapted to accommodate the current situation.

So much for theory. There are a couple of main points I want to make.

Our baseline level of activity varies a whole lot. Even within the course of a week we can go from days where we do a lot, to days where we chill. This means that determining what is an appropriate level of activity needs to be context specific. The level of activity we engage in (and the pattern) can be intentionally changed. What this means is we can all choose (or be constrained) to do more, or less, depending on the situation and the goal. And what’s more, we do this all the time. We can intentionally grind up a hill, increasing our pain, so we can get to the top. We can also decide not to do the vacuum cleaning today because we’re too sore, or because we judge that it’s not as much of a priority as remaining calm while making dinner.

We, and people with pain, make decisions about what we will and won’t do on the basis of a whole lot of different factors, and we do this fluidly throughout the day, every day.

What seems important to me is that we help people living with pain establish flexibility in the ways they go about doing things. We need to help people make choices rather than feeling pushed into overdoing, or underdoing. It’s that knowledge that we can choose to push to the top of the hill (and pay the consequences in feeling out of breath), or we can choose not vacuum the floor today (and live with the dirt and dog hair a day longer). It’s also about knowing that we can be flexible and use different ways of achieving these outcomes depending on our values, energy, people around us, and other priorities.

I’m not sure this has been entirely factored into Van Damme and Kinderman’s proposal, but I do agree with them that we need to pay more attention to context and intention when we look at the ways people go about daily life.

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3 comments

Historically, I’ve had this conversation countless times. Do less, do more, pacing, etc. Your post resonates with me. For those with chronic pain, I’ve started thinking these comments continue placing me in an instructor position when they (the patient) may benefit from taking charge.

Is it fair to recommend: “Do what you want with the understanding of outcomes. Do more than you are used to and you may have an increase in pain. Do less than normal and nothing gets done. You’re in charge. You determine how you want to proceed. The good news is you’re not going to damage or injure yourself by doing more activity.”

Exactly! I think we might need to help people understand the consequences, let them know the potential long-term problems, give them skills to manage the flare-up if/when it happens, but then it’s time to stand back.